Fatal Large-vessel Cerebrovascular Infarct Presenting With Severe Coronavirus Disease 2019 in a 39-year-old Patient

A Case Report

Nicolas Koslover; Marc Hardwick; Alexander Grundmann; Tamara Levene


J Med Case Reports. 2021;15(538) 

In This Article

Emergency Presentation

A 39-year-old white male developed sudden onset dysphasia while at home. An ambulance was called approximately 33 minutes following symptom onset, by which point he had begun to exhibit right-sided hemiplegia and facial weakness. The patient had been self-isolating at home for approximately 2 weeks owing to symptoms of cough, fever, shortness of breath, and vomiting.

He presented to the emergency department 2 hours and 24 minutes following the onset of symptoms. The patient was reported to have no past medical history and took no medications. Neurological examination confirmed right facial, leg, and arm weakness with associated right-sided sensory loss. He remained dysphasic and had evidence of dysarthria. NIHSS score was calculated as 13 and suggested a right partial anterior circulation stroke. Computed tomography (CT) head imaging 8 minutes after arrival was reported normal. Thrombolysis with recombinant tissue plasminogen activator (r-TPA) was initiated 56 minutes following arrival. A repeat NIHSS hours following thrombolysis was recorded as 18.

The patient was also tachypneic with respiratory distress and sinus tachycardia. Capillary blood glucose was measured as 27.6 mmol/L. Arterial blood gas analysis on 21% oxygen revealed type 1 respiratory failure with a partial pressure of oxygen (PaO2) of 5.85 kPa. He was started on 10 L/minute of oxygen. Chest X-ray revealed extensive bilateral peripheral predominant opacification involving upper mid and lower zones. High-resolution CT chest (Figure 1) was formally reported to show moderately severe bilateral ground-glass changes affecting all lobes, consistent with COVID-19-related features. Nasopharyngeal aspirates for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were taken and later returned negative; however, in view of his previous symptoms and CT chest findings, he was deemed COVID-19 positive and isolated.

Figure 1.

Computed tomography Thorax showing considerable covid pneumonitis

Blood tests revealed a C-reactive protein (CRP) of 150 mg/L, but full blood count, clotting studies, and thyroid, renal, and liver function all returned normal. Hemoglobin A1C (HbA1C) was raised at 109 nmol/mol, and a random lipid profile revealed raised triglycerides (5.24 mmol/L) and non-HDL cholesterol (3.58 mmol/L) along with reduced HDL cholesterol (0.92 mmol/L).

Initial therapy with empiric broad-spectrum antibiotics was initiated for possible aspiration pneumonia. Over the subsequent 48 hours, Glasgow Coma Score (GCS) remained between 12 and 14, and inhaled oxygen was reduced to maintain target oxygen saturation.